Should CVVHD be 1:1

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Should it be required that pts on CRTs be kept at a 1:1 ratio? I have a very unstable pt on CVVHD but also have to take on another pt cause my hospital doesn't require 1:1. I think it is ridic because my other patient gets super neglected while I'm constantly monitoring and managing this guy. We have a great suport system in my unit, but it all falls back on my nursing license. I can't seem to get my nurse manager to grasp on to my argument though...

How do you mean your patient is unstable? BP/HR, pulmonary? CVVHD is NOT a 1:1 at my hospital, we try to make it a 1:1 if able however if the staffing does not allow then there is really nothing we can do about it. If the patient is unstable meaning....more than 1 vasopressor and just plain SICK!!!, then we will triple up another RN so that the CVVH can be 1:1....Just because a patient is on CVVHD should not dictate a 1:1 status.

You are only responsible for the assignment you accept. If you feel that you are jeopardizing a patients care, you have the legal right to refuse the assignment on behalf of safety. Talk with your administrators in an open forum.

1:1 vent??? I need to work there. Its not atypical for me to get 2 vented patients,... but sometimes with the right sedation their easier anyway .

As for cvvhd,.. my unit tries to keep it 1:1 but that is not guaranteed. I don't believe they triple any nurses to get a 1:1 ratio. As long as the patient is not extremely critical then its usually not a problem. Its just hard at times when the filter clots and it takes 40minutes to start it up back again. there is either a delay in starting it back up or someone elses meds are late, etc.

CVVHD is indicated in patients who are unable to tolerate intermittent hemodialysis, usually for hemodynamic reasons, therefore by default, "unstable." The machine itself is more labor intensive than an IABP which is ironically the more acute therapy of the two. The patient's blood volume is being extracted extra corporally, therefore the primary rational for 1:1 would be safety, and secondary would be for maximum therapeutic management.

The primary reason the private sector doubles up such an assignment is for labor cost effectiveness and no other reason period. Management can double talk the issue, but there it is. I am a Government sector RN, so I (and my patients) are a bit luckier than most.

So how do you deal with this?

Keep two things in mind to determine your actions, "Standard of Care" and "The Prudent Nurse Standard." For the first ABC's, medications, TX and analysis dictate priorities. For the later, effective and very visible (think witnesses) resource utilization, (i.e. Charge Nurse, colleagues, supervisor,..etc.).